<div id=tiga_ba>
	<div id=tiga_baa>Tambah Master Diagnosis ICD10</div>
	<div id=tiga_bab></div>
	<div class=clear></div>
</div>
            
<form action="utama.php?module=mod_mdiagnosis&act=simpan" onsubmit="return gsValidate('kode|nama','Kode ICD10 Harus Diisi|Nama Diagnosis Harus Diisi','required|required');" method="post" enctype="multipart/form-data">
	<table style="margin: 10px 15px 10px 15px;">
		<tr>
			<td>Kode ICD10</td>
			<td>
				<input name="kode" type="text" class="input_small" id="kode"/>
				<span class="red">*</span>
			</td>
		</tr>
		<tr>
			<td>Diagnosis</td>
			<td>
				<input name="nama" type="text" class="input" id="nama"/>
				<span class="red">*</span>
			</td>
		</tr>
		<tr>
			<td>Keterangan</td>
			<td>
				<textarea name="keterangan" class="input" id="keterangan" rows="3"/></textarea>
			</td>
		</tr>
		<tr>
			<td>Not Klaim</td>
			<td>
				<input type="radio" name="not_klaim" id="not_klaim" value="Y"/>Ya
				<input type="radio" name="not_klaim" id="not_klaim" value="T" checked/>Tidak
			</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td><input name="submit" type="submit" class="button" value="Simpan" /></td>
		</tr>
	</table>                
</form>		
            
        